GIS-K-25

ACUTE APPENDICITIS
Appendiceal Mass / Abscess



INTRODUCTION

The appendix is :

-Wormlike extension of the cecum (vermiform appendix).

-Length is 8-10 cm (ranging from 2-20 cm).

-Fifth month of gestation

-Several lymphoid follicles.

Etiology:
Obstruction of the lumen appendix followed by infection

Catarrhal appendicitis.
-lymphoid hyperplasia (60% children)

-Gastro enteritis
-Virus
-Acute respiratory infection
-Mononucleosis

Obstructive appendicitis
-fecalith 35% adults.

-foreign body / parasites (4%)

- tumors (1%)




Pathophysiology

Wangensteen proposed
1. Closed loop obstruction
2. Increase in luminal pressure.
3. Exceeds capillary pressure causes mucosal ischemia
4. Luminal bacterial overgrowth and translocation bacteria across the
appendiceal wall result :
-Inflammation
-Edema
-Necrosis perforation occur about 48 hours .

If the body successfully walls off the perforation Appendiceal Mass

If the perforation is not successfully walled off Diffuse peritonitis will
develop.







Problem:

Appendicitis can mimic several abdominal conditions.

Laboratory test
Imaging investigation

Statistics report
1 of 5 cases is misdiagnosed

Normal appendix is found in
15-40% Emergency appendectomy.(Negative Appendectomy)
Differential diagnosis of acute appendicitis
Surgical
Acute Intestinal

obstruction

Intussusception

Acute cholecystitis

Perforated

peptic ulcer

Mesenteric adenitis

Acute Meckel's diverticulitis

Acute Pancreatitis

Medical
Gastroenteritis
Basal Pneumonia dextra
Terminal

ileitis




Urological
Right

ureteric colic

Right pyelonephritis

Urinary tract infection

Right Acute epididymitis

Gynaecological

Ectopic

pregnancy

Ruptured ovarian follicle

Torted ovarian cyst

Salpingitis/pelvic

inflammatory disease




Differential diagnosis of appendicitis appendicitis
can mimic several abdominal conditions.

Lab Studies:

Complete blood cell count
A mild elevation of WBCs (ie, >10,000/L)

Urinalysis

Mild pyuria relationship of the appendix with the right
ureter.

Severe pyuria in UTI.

For women of childbearing age,
Ectopic pregnancy test urin (beta-hCG)

























On physical examination

Lying down

Flexing their hips

The most common symptom of appendicitis is :
- Acute abdominal pain.
- Epigastric or Periumbilical pain migrating to the
right lower quadrant (RLQ) of the abdomen.
- Vomiting, nausea, and anorexia
- Afebrile or has a low-grade fever , 38 C

Higher fevers are associated with a perforated appendix


Special maneuvers

McBurney sign

McBurney's point
it is only the area
of greatest tenderness

Blumberg sign

Rovsings Sign

Dunphy sign Cough Test

Obturator sign

Psoas sign

Markle sign



Location appendix during pregnancy


INDICATIONS

Consider an appendectomy for patients with a
history of :

Persistent abdominal pain
Fever
Clinical signs of localized or diffuse peritonitis
Especially if leukocytosis is present.





















Imaging Studies

Abdomen plain film:
Fecalith within the appendix
Urolithiasis right middle third







MANTRELS SCORE
Characteristic Score
M = Migration of pain to the RLQ 1
A = Anorexia 1
N = Nausea and vomiting 1
T = Tenderness in RLQ 2
R = Rebound pain 1
E = Elevated temperature 1
L = Leukocytosis 2
S = Shift of WBC to the left 1
Total 10
A score of 7 or more is strongly predictive of acute appendicitis.

Alvarado score 1986
Sonography

Advantages of sonography

1. Noninvasiveness,
2. Short acquisition time
3. Lack of radiation exposure
4. Potential for diagnosis of
other causes of abdominal
pain
5. Pediatric patients
6. Women of childbearing age.
7. Pregnant women
normal less than 6 mm
CT scan

-Oral contrast medium
-Rectal Gastrografin enema

Reserved for patients
-Uncertain diagnosis
-Severe obesity.
more than 6 mm
If the clinical picture is unclear

Short period (4-6 h) of watchful waiting

USG / CT scan
-May improve diagnostic accuracy

Without a definite diagnosis
- return for continued or recurrent symptoms
- follow-up examination in 24 hours.
Complications
Perforation
General Secondary Peritonitis
Appendiceal Mass
Appendiceal Abscess
Pylephlebitis is suppurative thrombophlebitis of the
portal venous system
Hepatic absces
Chills
High fever
Jaundice

TREATMENT
Medical therapy

Resuscitated adequately with fluids .

Preoperative prophylactic antibiotics
-Acute Appendicitis single agent second-generation
cephalosporin.
-Perforated appendix triple antibiotic therapy
Ampicillin , gentamycin , metronidazol

Antibiotic prophylaxis should be administered before every
appendectomy.

Antibiotic treatment may be stopped.
-Becomes afebrile
-WBC count normalizes





Two approaches to appendectomy

1. Open Emergency Appendicectomy ( Appendectomy)


2. Laparoscopic appendectomy

If normal appendix removed need to look for:

- Meckel's diverticulum

- Acute salpingitis

- Crohn's disease





If the body successfully walls off the localized perforation

Appendiceal Mass

RLQ mass
The pain may actually improve.
Symptoms do not completely resolve.
Still have right lower quadrant pain
Decreased appetite
Change in bowel habits (eg, diarrhea, constipation)
Intermittent low-grade fever.


Treatment of

Appendiceal Mass
Nonoperative management
Becomes walled off by omentum and ajacent viscera.
Initially treated with intravenous broad-spectrum antibiotic

Appendiceal Abscess USG or CT scan
-Percutaneous aspiration
-Drain placement
Intravenous antibiotics are continued until the patient
- afebrile for 24 hours
- return of normal gastrointestinal function
- normal WBC count with a normal differential.
At this time, patients are switched to oral antibiotics for a total antibiotic
course of 10-14 days.

Traditionally, interval appendectomy is performed 6-8 weeks
later.
Acute Appendicitis Appendicitis Perforation